The systemic problems of global health care are illustrated well by a breakthrough study on heart health in the latest New England Journal of Medicine.
The idea is to insert a prosthetic valve over the failing one using a catheter, a technique called Transcatheter Aortic-Valve Implantation (TAVI).
The results are shown at right. About 31 percent of the TAVI patients were dead after a year, against 51 percent of the control group. (That's the black on the chart.) But just as important, those who survived were in better condition than those in the control group -- about one-quarter had well-functioning valves. (That is shown in blue.)
It's a great result, especially since TAVI does not require opening up the chest, exposing and stopping the heart, and all the costs and risks that entails.
Age and heart disease can cause the aortic valve to stop opening, a condition called stenosis. About 300,000 people suffer from this condition. About one-third of these patients can't undergo surgery. Most die within a year of diagnosis.
Over time it may be possible to use TAVI instead of surgery. Proving that this works for those who can't handle surgery is really a first step. It's a big success. On a per-patient basis, it could save money as well as lives.
But what happens when technologies like this become routine, when being told "you have aortic stenosis" is no longer a death sentence? More people live longer, but total costs rise.
Thus we have the problem of medical technology writ large. Even if new procedures cost less per-patient, they cost the system more as they are used on more patients.
Since the procedure seems to save lives, pressure is now going to build to have TAVI covered under Medicare. Present Medicare rules give the agency no choice, just as with new drugs. Once something works, once it's approved, the decision on whether to use it falls to the doctor. The system can't make choices.
Well, other health systems make choices. European systems make choices. Drugs, procedures and technologies must prove they are cost-effective before the common pool pays for them. And there are active political debates about even "cost-effective" procedures, asking whether they are worth enough to society to perform them on people at specific ages.
Whether the present U.S. health reform effort succeeds or is pulled down, the choice is not being made, the question isn't even being broached. That went out of the law as soon as someone screamed "death panels."
But technology is going to continue marching forward. Rationing is real, it will grow, and the only question will be whether it's done based on price, on a patient's income, or based on some other measure.